OCULAR INJURIES

(1) Eyelid Injuries - hematoma - laceration (2) Orbital Floor Fracture

(3) Globe Injuries - blunt injuries - conjunctival laceration - corneal abrasion/ foreign body - open globe injuries - chemical injuries

Eyelid (or Periorbital) Hematoma

most common type of blunt eyelid injury resolves spontaneously supportive management only: cold compress analgesics

complete ocular exam to rule out associated trauma to globe or orbit (such as an orbital floor fracture)

Eyelid Laceration

treated with primary repair important to examine globe for associated injuries

Case: 17 y/o male punched on the right periorbital area, upon ocular examination he is noted to have restriction of upward gazewhat would you suspect?

consider an orbital floor fracture

Orbital Floor Fractureblunt trauma increased intraorbital pressure weak part of orbit (orbital floor) unable to withstand pressure fracture & possible downward displacement of orbital structures

Signs/Symptomsrestricted vertical eye movements & diplopia - May either be due to edema or entrapment of the inferior orbital structures.

Enophthalmos (severe cases) backward or downward globe displacement

Other signs/symptoms : subcutaneous emphysema hypoesthesia in the distribution of the infraorbital nerve (ipsilateral lower lid, cheek)

Work-up : plain x-ray (Waters) CT is preferred for better visualization of the extent of the fracture (specially if suspecting herniation of ocular structures)

Waters view

CT Scan

TreatmentNo herniation of ocular structures observe oral antibiotics/ anti-inflammatory Confirmed herniation of ocular structures surgical repair

Blunt Injuries to the Globe

Case : 25 y/o male punched on the left periorbital area complaining of eye redness (no other symptoms)impression?

Traumatic Subconjunctival Hemorrhage

Traumatic Subconjunctival hemorrhage blunt globe trauma rupture of conjunctival blood vessels collection of blood under the conjunctiva

painless does not affect vision no reported complications does not require any treatment Management : reassure patient that condition resolves spontaneously within 2 to 3 weeks

Traumatic Corneal Edema swelling and fluid accumulation in the cornea

Signs/ Symptoms : decrease in vision halos around lights corneal whitening and folds with an intact epithelium

Management : topical steroids topical hypertonic saline to draw water out of a swollen cornea

Case : 12 y/o male hit on the left eye by a pellet, upon examination you note blood in the anterior chamberdiagnosis?

Traumatic HyphemaHyphema is blood in the anterior chamber secondary to blunt trauma. Most hyphemas result from tears in the anterior face of the ciliary body. (Shingleton. Eye Trauma.)

Hyphema

Grading of HyphemaGRADE I II III IV BLOOD IN AC 50 mmHg for 2 days or >35 mmHg for 7 days to avoid optic nerve damage (2) early corneal blood staining w/c may progress to corneal opacity (3) gr. 4 hyphema unresolving for >5 days(Shingleton et. al, Eye Trauma)

PrognosisIf hyphema is 1/2 of AC guarded prognosis, incidence of increased intraocular pressure is 85% & associated with more complications.(Kanski, J. Clinical Ophthalmology.4th ed.)

Traumatic IridodialysisSeparation of the iris root from its base

Small defects may be asymptomatic

Large defects may induce visually disturbing glare and diplopia.

Management : a small iridodialysis may be left alone visually symptomatic large iridodialysis may need to be surgically repaired

Traumatic Cataract (rosette or flower shaped cataract)

Lens subluxation (partial displacement)

Lens dislocation (completely displaced lens)

Management : Surgical (lens extraction with insertion of an intraocular lens prosthesis)

Commotio RetinaeRetinal concussion/ contusion Edema and disruption of the outer retinal layers

Commotio RetinaeSigns/ Symptoms : May have decreased vision or asymptomatic Fundus exam reveals an area of retinal whitening

No treatment most cases resolve spontaneously

Choroidal Rupture

No direct intervention. If the overlying retina is unaffected, patients will retain good vision.

Traumatic Retinal Break

Management : Laser photocoagulation to prevent retinal detachment.

Traumatic Optic NeuropathyMost common etio: blunt trauma to globe or orbit shock waves intracanalicular optic nerve (contusion injury) optic nerve edema & ischemia

Traumatic Optic NeuropathySigns/ Symptoms : decreased vision deficient color vision visual field defect optic disc pallor (occurs several weeks after injury) afferent pupillary defect (pupillary dilatation instead of constriction in response to light)

right eye is normal, left eye with (+) RAPD

Management : (controversial) High dose IV steroids Natl Acute Spinal Cord Injury Study : improved sensory & motor function of pxs w/ spinal cord injury treated IV methylprednisolone

Observation Intl Optic Nerve Trauma Study : no clear benefit for utilizing steroid therapy or surgical decompression as treatment options Surgical decompression

Conjunctival Laceration (With Subconjunctival Hemorrhage)

Signs/ Symptoms : slight eye pain slight redness foreign body sensation subconjunctival hemorrhage

conjunctival lacerations heal spontaneously, no need for surgical repair prophylactic antibiotic eye ointment It is very important to rule out associated injury to the sclera, specially in cases of full thickness conjunctival lacerations.

Case: 27 y/o female apparently hit by her babys finger, complaining of eye pain, tearing, upon examination you note a corneal epithelial defect impression?

Corneal AbrasionDefect in the corneal epithelium

Flourescein Staining

s/sx : foreign body sensation tearing eye redness hx of scratching or being hit by a fingernail or paper edge may have slight eyelid swelling

Corneal abrasions usually re-epithelialize within 24-48 hours Management Prophylactic topical antibiotic Topical nsaids for pain Do not give topical steroids to prevent secondary infection

Secondary infection of may progress to corneal ulceration

Penetrating Corneal Foreign Body

Presentation : Hx of working w/ a metal grinder Foreign body sensation Tearing Conjunctival injection

management : foreign body removal with treatment of the resulting corneal abrasion eyelid eversion to check for additional foreign bodies

Open Globe InjuriesFull thickness scleral and/or corneal lacerations Perforating type of injuries Considered as ocular emergencies

full thickness scleral laceration

scleral laceration

full thickness scleral laceration : poor visual acuity (+) presence of uveal tissue (+) presence of vitreous (clear gel like substance) Mgt : surgical repair

Full Thickness Corneal Laceration

PresentationPain, visual acuity Irregular pupil secondary to iris prolapse Shallow or flat anterior chamber (due to aqueous leakage)

Treatment : Surgical repair as soon as possible

Chemical InjuriesAcid burns (ex. exploded car batteries) coagulation necrosis usually confined to surface tissues Alkali burns (ex. detergents, drain cleaners) liquefaction necrosis more potential to damage inner structures long after the initial insult

ocular examination is done only after copious irrigation irrigation for 15 to 30 min. or until pH is normalized (litmus paper) evert lids & sweep fornices to remove crystallized particles

Grading of SeverityGr. 1 clear cornea, no limbal ischemia excellent prognosis Gr. 2 hazy cornea but iris details still clearly seen, 1/3 to of limbus guarded prognosis

Gr. 4opacified cornea ischemia involving >1/2 of limbus poor prognosis

Complications may include: (1) symblepharon formation

(2) corneal & conjunctival necrosis (3) limbal ischemia with loss of limbal stem cells resulting in vascularization & opacification of the cornea

(4) corneal ulceration

(5) iris or lens damage (6) ciliary body epithelium damage resulting in impaired ascorbate secretion (w/c is essential for corneal repair)

OCULAR THERAPEUTICS

Drops - most common form of ocular drugs - short duration - avoids systemic toxicity Ointments - provide a longer contact time - may temporarily induce blurring - slow onset - avoids systemic toxicity

Classification(1) Anti-infectives antibiotics, antivirals & antifungals antibiotics may also be given as prophylaxis prior to or after any ocular surgery

(2) Anti-inflammatory drugs steroids inhibits phospholipase A2 causing dec. production of prostaglandins & leukotrienes nsaids inhibits cyclo-oygenase dec. production of prostaglandins

(3) Ocular anesthetics(a) Topical provide anesthesia to conjunctiva, cornea & ant. sclera non-invasive, short duration - suitable for short procedures do not provide anesthesia to eyelids, intraocular structures & EOM (b) Intraocular most commonly used is 1% preservative free lidocaine usually given as adjunct to topical anesthetics so that ant. segment structures are also anesthesized

(c) Orbital administered via injection around or behind the globe longer duration, suitable for lengthy procedures provide full anesthesia to eye and extraocular stuctures such as the eyelids & EOMs may inadvertently cause hemorrhage, scleral perforation or optic nerve trauma

(4) Anti-glaucomaBeta blocker lowers IOP by aqueous production ex: timolol, betaxolol Prostaglandin analogue lowers IOP by uveoscleral outflow ex: latanoprost Adrenergic agonist alpha 2 agonist - (dual mechanism) lowers IOP by aqueous production and uveoscleral outflow ex: brimonidine

Carbonic anhydrase inhibitor lowers IOP by aqueous secretion through direct inhibition of carbonic anhydrase ex: dorzolamide, oral acetazolamide Hyperosmotic agent lowers IOP by drawing fluid from the eye to the intravascular space ex: mannitol Cholinergic agonist lowers IOP by aqueous humor outflow; also induces miosis ex : pilocarpine

(5) Mydriatics, Cycloplegics & MioticsMydriatics eg. Phenylephrine (sympathomimetics) stimulate alpha-1 receptors in pupillary dilator muscle producing mydriasis Cycloplegics eg. Tropicamide, Atropine parasympatholytics (cholinergic antagonists) which block the release of Ach paralysis of the pupillary constrictor For maximal pupillary dilation, a mydriatic & a cycloplegic are used simultaneously.

Mioticsdirect acting parasympathomimetic ex: pilocarpine stimulates cholinergic receptors to release Ach pupillary constriction indirect acting parasympathomimetic ex: echothiopate cholinesterase inhibitor (prevents Ach breakdown) *carbachol combination of a direct acting parasympathomimetic and a cholinesterase inhibitor

(6) Anti-neoplastic agentsMitomycin-C and 5 Fluorouracil used as adjunctive tx in glaucoma filtering surgery to prevent fibrosis and scarring thus enhancing long term survival of the filter Cyclosporine increases tear production in severe dry eyes (keratoconjunctivitis sicca) in which deficiency of tears may have been suppressed due to chronic ocular irritation

(7) Botolinum toxinBlocks acetylcholine release inducing muscle paralysis. Used to control disturbing blepharospasms and hemifacial spasms.

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